How ongoing care works with your family doctor (médico de familia)

Key rules

• Where care happens: Routine chronic care is run at your health centre by your family doctor and nurse.
• Joining: Inclusion is normally a clinical decision after diagnosis, and you can ask to be included.
• Regional differences: Programme names, criteria and review schedules differ by region, so ask your care team for yours.
• Changes in control: Poor control or a new treatment means more frequent reviews.

The short version

Chronic follow-up is run in primary care, at your health centre. You are not sent to a hospital for routine checks. Your family doctor (médico de familia) and a nurse share the work. You get scheduled reviews, and many conditions have a nurse-led programme.

Who can join a programme

You need to be registered with a health centre, with a health card and an assigned doctor and nurse. If you then have a qualifying diagnosis, you can be included.

There is usually no separate application. Your doctor or nurse records the diagnosis, books an initial assessment and sets a review plan. You can also ask your doctor or nurse to include you.

Each region runs its own programmes, so names and criteria differ. Common ones cover:

• type 2 diabetes
• high blood pressure and cardiovascular risk
• COPD and asthma
• heart failure
• chronic kidney disease
• obesity and high cholesterol
• blood-thinner (anticoagulation) monitoring
• care of older, frail people and people taking many medicines

Some regions also have programmes for palliative care, mental health and home care.

What the nurse does

The nurse is usually the main person you see. Typical tasks:

• initial and regular assessments
• checking blood pressure, weight and glucose
• foot exams if you have diabetes
• breathing tests and inhaler-technique checks for lung conditions
• advice on diet, exercise, smoking and managing your own condition
• reviewing how you take your medicines
• booking follow-ups and, if needed, home visits
• coordinating with your doctor and other services

In many regions, nurses can also prescribe certain medicines and devices under set protocols. Your doctor still handles anything outside those protocols.

How often you are reviewed

How often depends on your condition and how well it is controlled. Typical patterns:

• Stable type 2 diabetes: every 3 to 6 months, with a fuller review once a year.
• Controlled high blood pressure: once or twice a year, sooner if your treatment changes.
• Stable COPD or asthma: at least once a year.
• Heart failure and complex cases: more often.

Poor control or a new treatment shortens the gap. Ask your care team for your exact schedule and the regional protocol that applies. The timeline and checklist below show the pattern and what to ask.

When your needs grow

If your situation becomes complex, you may be referred to a nurse case manager (enfermera gestora de casos). This is a community or primary-care nurse who coordinates your care between your doctor, the hospital, social services and your family. She can arrange home care, equipment or day centres, plan hospital discharge and follow you at home.

Referral usually comes from your doctor, nurse or hospital team. It is aimed at people with complex chronic illness, severe dependency, advanced disease, or frail older people leaving hospital, especially when family support is thin. Not every health area has this service, and the name and criteria vary by region. Ask your health centre what exists locally.

Timeline and deadlines

• Stable type 2 diabetes review in primary care: about every 3 to 6 months

• Complete diabetes review: once a year

• Review of stable COPD or asthma: at least once a year, more often if not stable

• Review after poor control or a new treatment: sooner than your usual interval

Review intervals follow regional protocols and your own control, so confirm your exact schedule with your care team.

Checklist

• Ask your family doctor or nurse whether you can be included in the programme for your condition.

• Book your next review before you leave the health centre.

• Ask your nurse to explain which checks they do, such as blood pressure, weight, glucose, foot exams or inhaler technique.

• Tell your nurse or doctor sooner if your control gets worse or your treatment changes, so the review can be brought forward.

Frequently asked questions

Do I have to apply to join a chronic care programme?

No, you normally do not apply, because joining is a clinical decision made by your family doctor or nurse after a diagnosis. They record the diagnosis, book your first assessment and set a review plan.

What is a nurse case manager and who gets one?

A nurse case manager (enfermera gestora de casos) is a nurse who coordinates care for people with complex, high-need situations, linking your family doctor, the hospital, social services and your family. Your family doctor, nurse or hospital team usually refers you. Typical cases are severe dependency, advanced disease, frail older people leaving hospital, or people with little family support. Not every health area offers this service.

Which conditions have chronic care programmes in health centres?

Common programmes cover type 2 diabetes, high blood pressure, COPD, asthma, heart failure, chronic kidney disease, obesity and high cholesterol. There are also programmes for blood-thinner monitoring and for older, frail or polymedicated patients. Many regions add palliative care, mental health and home care.

Can the nurse prescribe my medicines in a chronic programme?

Yes, in some cases nurses can prescribe certain medicines and devices, but only with legal authorisation and under set protocols. Your doctor still leads your treatment, and the nurse coordinates with them.